Omnilux Service Request Form Omnilux inquiries/customers may obtain general support by completing the Contact Sales Form or by calling GlobalMed Technologies at +1-707-224-0200. Business hours are M-F 9:00 a.m. to 5:00 p.m. PST To request service on an existing device, please complete the form below. A service representative will contact you within 24 business hours. Facility Information *Required Field Company Name * First Name * Last Name * Direct Phone Number with Ext.* Email * Shipping Address Address * City * State/Province * —Please choose an option—Non-USALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip/Postal Code * Country * —Please choose an option—United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEswatiniFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City)HondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedonia, TFYRMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt Vincent & GrenadinesState of PalestineSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamYemenZambiaZimbabwe Product Information Product Type * —Please choose an option—Revive (Red) HeadBlue HeadPlus (IR) HeadBase Unit Serial number labels are affixed to all Omnilux Bases and Heads. The base label is located at the back or bottom of the device. The head label is located along the edge of one of the light panels, sometimes between panels. Serial Number(s) e.g. ??######* Date of Manufacture (yyyy-mm-dd)* Description of Issue * Upload Images Image #1 Image #2 Click to add another product Product Information Product Type * —Please choose an option—Revive (Red) HeadBlue HeadPlus (IR) HeadBase Unit Serial number labels are affixed to all Omnilux Bases and Heads. The base label is located at the back or bottom of the device. The head label is located along the edge of one of the light panels, sometimes between panels. Serial Number(s) e.g. ??######* Date of Manufacture (yyyy-mm-dd)* Description of Issue * Upload Images Image #1 Image #2 Click to add another product Product Information Product Type * —Please choose an option—Revive (Red) HeadBlue HeadPlus (IR) HeadBase Unit Serial number labels are affixed to all Omnilux Bases and Heads. The base label is located at the back or bottom of the device. The head label is located along the edge of one of the light panels, sometimes between panels. Serial Number(s) e.g. ??######* Date of Manufacture (yyyy-mm-dd)* Description of Issue * Upload Images Image #1 Image #2